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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844789/psn-pdf
    January 01, 2021 - Patient preferences in cases of Inter-system Medical Error Discovery (IMED). … Patient Preferences in Cases of Inter-system Medical Error Discovery (IMED). … https://psnet.ahrq.gov/issue/patient-preferences-cases-inter-system-medical-error-discovery-imed Clinicians … This study used simulated cases to explore patient preferences for error disclosure when the disclosing … https://psnet.ahrq.gov/issue/patient-preferences-cases-inter-system-medical-error-discovery-imed https

  2. White blood cell left shift in a neonate: a case of mistaken identity. | PSNet

    psnet.ahrq.gov/issue/white-blood-cell-left-shift-neonate-case-mistaken-identity
    March 30, 2022 - multidisciplinary review of severe maternal morbidity is associated with a reduction in preventable cases … September 8, 2021 WebM&M Cases Endometriosis: A Common … and Commonly Missed and Delayed Diagnosis June 24, 2020 WebM&M Cases … May 11, 2014 WebM&M Cases A "Reflexive" Diagnosis in … July 23, 2010 WebM&M Cases Physical Diagnosis: A Lost

  3. Masks-Surveillance-2-Appendix-Table-A-3 (xls file)

    effectivehealthcare.ahrq.gov/sites/default/files/masks-surveillance-2-appendix-table-a-3.xlsx
    March 23, 2020 - June 2014 Saudi Arabia 1 hospital Healthcare workers (HCWs) in 1 hospital with MERS outbreak 283 40 (cases … and 373 controls 35 (cases) 42% (cases) 29% physician 44% nurse/nurse midwife 4% housekeeping 11% lab … with SARS-CoV-1 seropositivity 91 cases and 657 controls Mean age not reported; 34.9% <26 years of … with SARS-CoV-1 seropositivity 47 cases and 426 controls 29 70% Physicians, nurses, care givers and … with SARS-CoV-1 seropositivity 29 cases and 98 controls Mean age not reported; 57% 29 to 39 years

  4. Hiding in Plain Sight | PSNet

    psnet.ahrq.gov/web-mm/hiding-plain-sight
    April 24, 2019 - Childhood HZ is rare, although cases have been reported in children as young as 4 months. … Cases of HZ can be missed when a full history and physical examination are not performed, or when the … Except for such cases with ocular involvement, delays in diagnosis generally carry little overall risk … Nosy Business April 1, 2010 WebM&M Cases … May 1, 2009 WebM&M Cases Autopsy Revelation

  5. PowerPoint Presentation; Deep-Root Your Data

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_deep_root_data.pptx
    December 01, 2017 - ) Percentage of SSIs JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY Total Cases 3 5 2 5 3 0 7 3 … You can also share data about individual cases that represent the infections. … So, rather than saying the SSI rate is 50 percent, perhaps share the five cases that developed SSI. … Identify which process measures were not present on those cases and share with your frontline staff. … Each case should be investigated to determine potential sources of infection. 8 Total Cases CY11 Q1

  6. The Excellence Report: Quality Measures for Colonoscopy (pdf file)

    digital.ahrq.gov/sites/default/files/docs/resource/Logan_ExcellenceReportQMs.pdf
    June 16, 2021 - (ASA classification) and the proportion of cases with each risk level. … For cases with withdrawal time documented, the proportion of cases with documentation < 6 minutes, between … Value measured: Number of cases where an adenomatous polyp is detected. … Inclusions: All cases are included in this measure. … Exclusions: Besides excluding cases performed on higher risk patients, cases are excluded if • the

  7. Medical malpractice lawsuits involving surgical residents. | PSNet

    psnet.ahrq.gov/issue/medical-malpractice-lawsuits-involving-surgical-residents
    August 20, 2018 - Investigators reviewed a legal database for malpractice cases involving surgical trainees between 2005 … During the 10-year period, 87 cases were identified. … Most cases involved perioperative management for elective surgery, and more than half of cases implicated … As with previous research on closed malpractice claims, a majority of these cases had an outcome of

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836998/psn-pdf
    April 27, 2022 - How will state medical boards handle cases involving disclosure and apology for medical errors? … How will state medical boards handle cases involving disclosure and apology for medical errors? … https://psnet.ahrq.gov/issue/how-will-state-medical-boards-handle-cases-involving-disclosure-and-apology … https://psnet.ahrq.gov/issue/how-will-state-medical-boards-handle-cases-involving-disclosure-and-apology-medical-errors … https://psnet.ahrq.gov/issue/how-will-state-medical-boards-handle-cases-involving-disclosure-and-apology-medical-errors

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836722/psn-pdf
    March 09, 2022 - Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping … Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping … https://psnet.ahrq.gov/issue/key-use-cases-artificial-intelligence-reduce-frequency-adverse-drug-events … https://psnet.ahrq.gov/issue/key-use-cases-artificial-intelligence-reduce-frequency-adverse-drug-events-scoping-review … https://psnet.ahrq.gov/issue/key-use-cases-artificial-intelligence-reduce-frequency-adverse-drug-events-scoping-review

  10. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. | PSNet

    psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
    January 29, 2021 - The ototoxicity in the cases presented may be  vestibular rather than cochlear in nature and therefore … Safety of gentamicin bladder irrigations in complex urological cases. … March 29, 2023 WebM&M Cases Distraction of the … March 15, 2023 WebM&M Cases Open wider: Failure … February 1, 2007 WebM&M Cases Right?

  11. Summary of USPSTF Final Recommendation: Screening for Syphilis Infection During Pregnancy (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/_CqYnP2r9XUSuDgkPpF9y8
    May 01, 2025 - In 2023, congenital syphilis rates were: º 9.3 cases per 100,000 live births in Asian women º 222.0 … cases per 100,000 live births in Black women º 125.0 cases per 100,000 live births in Hispanic/Latina … women º 680.8 cases per 100,000 live births in Native American/Alaska Native women º 295.6 live … births per 100,000 live births in Native Hawaiian/Pacific Islander women º 82.2 cases per 100,000 live … births in multiracial women º 57.3 cases per 100,000 live births in White women What are other

  12. Diagnosing Diagnostic Mistakes | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - As part of this research, we evaluated cases from the archives of AHRQ WebM&M to determine whether we … In this commentary, we will review two cases from the WebM&M archives to illustrate some potential sources … November 13, 2024 WebM&M Cases Techno Trip March … 1, 2005 WebM&M Cases Saline Flush Leads to Acute … June 23, 2009 WebM&M Cases Right? Left?

  13. An Outpatient 'Zebra' | PSNet

    psnet.ahrq.gov/web-mm/outpatient-zebra
    January 23, 2020 - October 1, 2009 WebM&M Cases Blind Spot June … 1, 2005 WebM&M Cases Not a Miscarriage June … 1, 2003 WebM&M Cases Hyponatremia Secondary to … Home Parenteral Nutrition Error May 26, 2021 WebM&M Cases … Citrate Mix-Up May 1, 2006 WebM&M Cases

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46419/psn-pdf
    April 12, 2019 - Investigators reviewed a legal database for malpractice cases involving surgical trainees between 2005 … During the 10-year period, 87 cases were identified. … Most cases involved perioperative management for elective surgery, and more than half of cases implicated … As with previous research on closed malpractice claims, a majority of these cases had an outcome of

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850340/psn-pdf
    June 14, 2023 - Assertive communication training for nurses to speak up in cases of medical errors: a systematic review … Assertive communication training for nurses to speak up in cases of medical errors: a systematic review … https://psnet.ahrq.gov/issue/assertive-communication-training-nurses-speak-cases-medical-errors- systematic-review-and-meta … https://psnet.ahrq.gov/issue/assertive-communication-training-nurses-speak-cases-medical-errors-systematic-review-and-meta … https://psnet.ahrq.gov/issue/assertive-communication-training-nurses-speak-cases-medical-errors-systematic-review-and-meta

  16. Don’t Bite Your Tongue. | PSNet

    psnet.ahrq.gov/web-mm/dont-bite-your-tongue
    September 18, 2024 - A review of the published literature by MacDonald included 35 cases of tongue or lip lacerations with … anesthesia literature, other care providers also have a role in preventing injuries during surgical cases … for Health Systems Science Curricula February 1, 2019 WebM&M Cases … December 14, 2022 WebM&M Cases Fecal Contamination of … October 26, 2022 WebM&M Cases Perioperative Anaphylaxis

  17. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet

    psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
    March 25, 2020 - March 29, 2023 WebM&M Cases Distraction of the … March 15, 2023 WebM&M Cases Open wider: Failure … 28, 2021 WebM&M Cases Hazards of Loading Doses … January 1, 2017 WebM&M Cases Situational ( … Un)Awareness September 1, 2011 WebM&M Cases

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48173/psn-pdf
    August 28, 2019 - Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common … Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common … Researchers describe their analysis of more than 600 cases discussed at educational radiology conferences … able to identify numerous opportunities for improving learning from error, including using positive cases … (e.g., near misses or difficult cases in which extra effort helped avert an error) and targeting teaching

  19. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet

    psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
    July 01, 2004 - Novel Drug Misuse July 1, 2004 WebM&M Cases … Call March 1, 2012 WebM&M Cases If You Say … June 21, 2006 WebM&M Cases Inpatient Stroke Management … August 30, 2023 WebM&M Cases Updates in the Management … September 1, 2004 WebM&M Cases Privacy Gone

  20. Language barriers to health care in the United States. | PSNet

    psnet.ahrq.gov/issue/language-barriers-health-care-united-states
    February 28, 2024 - February 28, 2024 WebM&M Cases Language Barrier April … July 13, 2009 WebM&M Cases All in the History March … 21, 2009 WebM&M Cases Failure to Latch September … July 10, 2008 WebM&M Cases Abnormal Volunteer Results … June 1, 2007 WebM&M Cases Language Barrier
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